Transscleral Photocoagulation to Treat ROP in Eyes with Media Opacity

It has been well established that laser treatment for type 1 prethreshold retinopathy of prematurity is effective in approximately 90 percent of treated eyes, avoiding retinal detachment.1 Transpupillary laser therapy is certainly the standard; however, there are circumstances in which transpupillary treatment may be difficult or impossible to perform thus allowing progression of retinopathy of prematurity. Many years ago in the circumstance of media opacity, cryotherapy was used. Cryotherapy was shown to be effective in the CRYO-ROP study many years ago.2 However it led to effusive retinal detachment, which was rather a common problem following cryotherapy. The introduction of transscleral diode laser retinal photocoagulation allows treatment of the peripheral retina in the face of media opacity. Since transscleral diode laser treatment ablates the ciliary body, it must be applied very cautiously, especially in the face of media opacity, to avoid excessive ciliary destruction and hypotony. The use of transpupillary illumination to identify the position of the ciliary body can allow safer delivery of treatment to the peripheral retina. Transscleral retinal photocoagulation can allow time for resolution of vitreous hemorrhage followed by additional transpupillary laser application if needed. Certainly, transpupillary retinal photocoagulation with the indirect laser is the standard of care worldwide, but there are rare circumstances in which transscleral diode laser can be very helpful. As pointed out by Dr. Parvaresh et al, posterior disease is more effectively treated with transpupillary diode laser retinal photocoagulation.3 I do not think that transscleral diode laser retinal photocoagulation will in any way replace transpupillary treatment. However, it is important to realize that such a modality does exist and does not seem to cause effusive retinal detachments often seen following cryotherapy. I think the authors are to be congratulated for pursuing this type of therapeutic intervention which in some circumstances will lead to a good outcome, avoiding vitreous surgery for media opacity.